Reprinted from "Suicide" issue of Visions Journal, 2005, 2 (7), p. 30-31
“I cut to see the blood and then I know that I am still alive” “If you won’t listen to my pain then you’re going to see it” “I go to the emergency because I am so lonely at home alone and there they have to pay attention to me” —
SAFE BC client quotes
Self-harm—what and why
Self-harm encompasses a variety of non-fatal self-injuring behaviours including cutting, burning, breaking bones and poisoning. These behaviours arise for a variety of reasons, but all of them speak of intense emotional distress in the person who deliberately hurts themselves.
The deﬁnition of self-harm is complex. It includes acts with suicidal intent and ones without suicidal intent. This distinction can be problematic for public understanding, research and effective intervention. Some acts of self-harm are really suicide attempts; others are ways of coping with overwhelming feelings and may be more habitual. In these latter cases, sadly, death often results accidentally.
Self-harm is on the increase, especially in youth; most are young women. Young males, however, are showing an alarming increase in rates of self-harm.2 By deﬁnition, self-harm focuses on one’s self, but it does affect others, especially loved ones. It is estimated that around 0.5% to 1% of the population self-injures.
Those who self-harm do it for different reasons—to punish themselves, to stop their inner pain, to gain a sense of control, and even for revenge (my own reason, at times). Often it is said they are seeking attention. But what they’re really doing is trying to tell people how bad they feel. Having being told for years not to talk about the pain they suffer, they have learned to use selfharm as a means of communication.
The suicide risk
People who have self-harmed are at greatly increased risk of suicide and should have access to assessment and support.3 Studies have shown that around one in 100 people seen at hospitals for self-harm will die by suicide within a year of the self-harm; this suicide risk is 100 times greater than the average.
The difference between self-harm and suicide, in my opinion, is often the intensity of the act. I believe that a lot of suicides are self-harming behaviours that have gone wrong. For example, someone might hurt themselves expecting that someone will come home at a certain time, but the expected person is delayed. This is often the case with overdoses.
Not all self-harming behaviour is attached to a will to die. Habitual self-harmers don’t want to die; they just want their pain to go away. One distinction that might be helpful for those trying to help someone who selfharms is that a person who truly attempts suicide seeks to end all feelings, whereas a person who self-mutilates seeks to feel better.6 Some people describe that they self-harm when they want to prove that they are alive, or they use it as a coping strategy to allow them to carry on living. In people who self-harm with suicidal intent, after the self-harming behaviour the thought of dying is often replaced with the desire to live—and this is when people will often reach out for help.
Unfortunately, it’s difﬁcult to predict the difference between the two types. One study found that the ‘seriousness’ of self-harm—measured by factors of the act itself, such as the method used, the extent of harm, the degree of reversibility of effects, or the type of treatment required—was not related to measures of suicidal intent as reported by the person. Depression and impulsivity were much more linked with the intent to die by suicide.7 That’s why it is so important to get help for someone who you know is hurting themselves, so that depression and suicide risk can be assessed.
SAFE helps stop the cycle of hurt
The act of self-harm is a behaviour. A behaviour is a choice—even when it doesn’t feel like one. Therefore, when a person begins to accept that self-harm is a behaviour, they can then gain control over it.
Self-Abuse Finally Ends (SAFE) offers a 10-week program for those who use self-harming behaviour to cope with inner pain. The program manual, Overcoming Self-abuse, speciﬁes boundaries and guidelines for creating a group process that nurtures hope, support, companionship, empowerment and acceptance. The program helps clients understand what triggers their self-abuse—for many people, self-abuse is triggered by patterns of unhealthy thinking (called cognitive distortions). Clients develop a conceptual map that identiﬁes the triggers that set their self-harming behaviour in motion. This helps them deliberately slow down their thinking process so they can deal with these triggers. Then, old coping strategies are countered with newer, healthier ones. SAFE also helps clients develop individual skills that help them identify and deal with their emotional reactions, formulate a variety of alternative strategies to deal with trigger events, and then choose and act on more constructive alternatives.
For someone who self-harms, turning to a support system when a trigger is on the horizon—rather that waiting for a full-blown crisis—is a very important strategy. It is most effective to have someone in the community to talk to as soon as the trigger registers. Family and friends can provide a strong system of support. Peer support developed through mental health clinical services is another source of help. Some people who self-harm may even ﬁnd Internet/online support.
The process of changing the behaviour of self-harm is a long and difﬁcult one. A person may have been selfharming for many years. As with an eating disorder or an addiction, change doesn’t happen immediately. It takes new skills, practice and support. But self-harming behaviour can be changed. There is hope.
About the Author
Mary was formerly Executive Director and a co-founder of Self Abuse Finally Ends (SAFE) in Canada and a manager with Spectrum, a borderline personality disorder program in Australia. Mary has overcome her own desire to self-abuse and now shares her knowledge with professionals, consumers and family members. Mary can be reached at firstname.lastname@example.org or 604-669-655
Samaritans. (2005). Selfharm and suicide. Information sheet retrieved July 12, 2005, from www.samaritans.org/know/ informationsheets/selfharm/ selfharm_sheet.shtm.
Owens, D., Horrocks, J. & House, A. (2002). Fatal and non-fatal repetition of self-harm: Systematic review. British Journal of Psychiatry, 181, 193-199.
24 Hours News Services. (2005, June 22). “Self-mutilation: Sharp cry for help.” 24 Hours: Vancouver, p.12.
Centre for Suicide Prevention. (2001, January). SIEC Alert #43: A closer look at self-harm. Calgary, AB: author.
Hawton, K. (1992). Suicide and attempted suicide. In E.S. Paykel (Ed.). Handbook of affective disorders (pp. 635-650). London, UK: Churchill Livingstone.
Favazza, A.R. (1989). Why patients mutilate themselves. Hospital and Community Psychiatry, 40(2), 137-145.
Plutchik, R., van Praag, H.M., Picard, S., et al. (1989). Is there a relation between the seriousness of a suicidal intent and the lethality of the suicide attempt? Psychiatry Research, 27(1), 71-79.
Haswell, D.E. & Graham, M. (2004). Overcoming self-abuse. London, ON: SAFE in Canada